ETD

• Bilateral Salpingo Oophorectomy
• counseling
• menopausal hormone therapy
• MHT
• quality of life
• surgical menopause

Background - Surgical menopause, induced by bilateral salpingo-oophorectomy, differs fundamentally from spontaneous menopause. In contrast to the gradual decline in ovarian function observed in natural menopause, surgical menopause results in an abrupt and complete loss of ovarian hormone production, leading to sudden and profound estrogen deprivation. The resulting clinical presentation is typically more severe and includes vasomotor symptoms, sleep and mood disturbances, genitourinary symptoms, arthralgia, and cognitive complaints. In addition, well-established long-term consequences affect cardiovascular, skeletal, and cognitive health. International guidelines recommend the use of menopausal hormone therapy (MHT), in the absence of contraindications, at least until the average age of natural menopause, particularly in younger women. Nevertheless, real-world evidence consistently demonstrates that MHT is markedly under-prescribed and poorly sustained in this population. An additional, less frequently investigated factor is the quality of peri-operative counseling, which may critically influence both the initiation and continuation of appropriate therapy.
Objective - This study aimed to assess two interrelated aspects of care in women undergoing surgical menopause: (i) the perceived adequacy of peri-operative counseling and (ii) the relationship between the timing of MHT initiation and symptomatic outcomes. We hypothesized that counseling is currently suboptimal and that earlier initiation of therapy is associated with improved symptom control.
Methods - This retrospective single-centre study included women who underwent bilateral salpingo-oophorectomy, either alone or in combination with hysterectomy, before the age of 55 years. Of 253 eligible patients, 144 (56.9%) completed a structured telephone follow-up and constituted the final study population (N = 144). Clinical and surgical data were retrieved from medical records. Climacteric symptoms were evaluated across six domains—vasomotor symptoms, insomnia, mood disturbances, arthralgia, genitourinary syndrome, and cognitive complaints—using a self-reported visual analogue scale (VAS). The percentage change in symptom severity (Δ%) between a defined reference time point and follow-up was calculated. Patients were stratified into three groups according to the timing of MHT initiation: never initiated (“never”), initiated at discharge (“from discharge”), and initiated upon symptom onset (“when symptomatic”). Perceived adequacy of discharge counseling and referral to a dedicated menopause clinic were also assessed. Between-group comparisons of Δ% were performed using analysis of variance, while categorical variables were analysed using the chi-square test; statistical significance was defined as p < 0.05. A non-parametric sensitivity analysis (Wilcoxon and Mann–Whitney tests) was additionally performed to confirm the robustness of the symptomatic findings and to verify that untreated women had not simply remained asymptomatic; this analysis covered eight symptom domains, adding asthenia and migraine to the six examined in the primary analysis.
Results - The study population largely consisted of appropriate candidates for hormone therapy, with a low burden of comorbidities, minimal frailty, and low anaesthesiological risk; recognised contraindications were rare. Despite this, MHT was prescribed at discharge in only 29% of patients and at early follow-up in 22%, while only 13.2% of women reported ongoing use and 61% never initiated therapy. Overall, 88.2% of participants expressed the need for improved counseling at discharge; notably, this perception did not differ across treatment groups (p = 0.893), indicating that dissatisfaction with counseling was independent of subsequent therapeutic decisions. Referral to a dedicated menopause clinic occurred in 24.3% of cases, most frequently prompted by the follow-up contact itself. Among treated patients, MHT was associated with significant symptomatic improvement in two domains. For vasomotor symptoms, improvements of 70.7% and 61.8% were observed in treated groups compared with only 2.8% in untreated women (p = 0.001), consistent with effect sizes reported in randomized trials. For arthralgia, the greatest improvement was observed in patients who initiated therapy at discharge (42.8%), significantly exceeding both the symptom-triggered and untreated groups (p = 0.042), suggesting a potential benefit of early initiation in this domain. No statistically significant differences were found for insomnia, mood, genitourinary, or cognitive symptoms. No statistically significant differences were found for insomnia, mood, genitourinary, or cognitive symptoms. The non-parametric analysis confirmed these findings: within-group improvement was significant in treated women across all domains but absent in untreated women, and the between-group difference favored treatment in every domain, with the largest effects for insomnia, vasomotor symptoms, and arthralgia. This argues against the possibility that untreated women had simply experienced milder symptoms.
Conclusions - In this cohort of women undergoing surgical menopause, MHT was markedly underutilized, despite the majority being suitable candidates and clear evidence of symptomatic benefit among treated individuals confirmed by non-parametric sensitivity analysis. The near-universal demand for improved counseling, and its independence from treatment uptake, identifies deficiencies in the informational process—rather than clinical contraindications or patient ineligibility—as a key and modifiable determinant of this therapeutic gap. These findings suggest a causal pathway in which adequate and timely counseling facilitates early initiation and sustained use of MHT, thereby optimizing both short-term symptom relief and long-term health outcomes. The results support the integration of structured peri-operative counseling, shared decision-making, early prescription in eligible patients, and systematic referral to dedicated menopause services into routine surgical care. The study’s limitations—including its retrospective single-centre design, the use of a non-validated questionnaire, heterogeneity within the untreated group, and limited size of certain subgroups—should be acknowledged and underscore the need for prospective studies employing validated assessment tools.